Transitional WorkGRANT$-EZ For small business - It’s easy Employer full, legal name (please print or type) Federal tax I.D. number Employer address (city, state, ZIP code) This is an Agreement by and between _______________________________________________________________ (hereinafter, “the employer”), Employer full, legal name with its principal place of business located at __________________________________________ , and the Ohio Bureau of Workers’ Compensation (hereinafter “BWC”), having offices at 30 W. Spring St., Columbus, Ohio 43215-2256, entered into the day, month and year set out below. Whereas, the Administrator of BWC, may issue a grant to defray the costs incurred by the employer who elects toparticipate in BWC’sTransitional Work Program Development Grants-EZ program, also known as the Transitional WorkGRANT$ (TWG)-EZ program, pursuant to Ohio Revised Code Section (ORC) 4123.29 and Ohio Administrative Code Rule (OAC) 4123-17-55 and4123-18-06, wherein the employermay receive grant monies for the development of a transitional work program; now Therefore, for good and valuable consideration, the sufficiency of which is acknowledged, the parties mutually agree tothe following: CONDITIONS PRECEDENT. Approval of a TWG-EZ grant is contingent upon the following criteria: The employer is eligible for a TWG-EZ grant only one time per policy number. Only state fundemployers or certain public employers are eligible for such a grant. TASK DESCRIPTION. The employer, in consideration of the grant given to it as a participant in the BWC’s TWG-EZ program promises to pay the transitional work developer for its work and to implement the program in good faith in accordance with OAC 4123-17-55, as amended, which shall be incorporated as if fully rewritten herein. Where applicable, the employer participating in the TWG-EZ program in consideration of the grant given to the employer, promises to fully comply with the program requirementsas outlined in the application,which shall be fully incorporated herein by reference. ELIGIBILITY AND DISTRIBUTION OF GRANT MONIES. The distribution of any TWG-EZ money for the employer participating in BWC’s TWG-EZ program is fully dependent upon available resources of BWC. The employer and BWC mutually understand and agree as follows. The employer may request a proposal from the current list of transitional work developers from BWC and then solicit proposals from these Developers. BWC shall not reimburse the employer or the transitional work developers for costs associated with preparing and submitting a proposal to the employer. Grant amounts will be based on the complexity of services needed as indicated in a proposal for transitional work services. Factors which may determine appropriate grant amounts may include the employer’s number of employees, job classifications, job analyses needed, and collective bargaining units. The grant monies shallnot exceed the maximum amount to which the employer is eligible, as delineated 2600.00 in the Transitional Work Development Reimbursement Limits document, which shall beincorporated as if fully rewritten herein. The maximum reimbursable amounts and rates shall be those that are in effect on the date of this agreement. The job analysis reimbursement amount per job analysis shall not exceed one hundred sixty dollars ($160.00), which shall be paid for the actual number of job analyses performed. Each job analysis shall consist of a certain length of observation and a certain length for report completion. The employer shall directly compensatethe transitional work developer for the developers’s services. BWC shall not reimburse the employer for costs not deemed eligible.BWC may monitor the employer’s and the transitional work developer’s content and implementation of transitional work services. The employer agrees to utilize the grant monies soley for the purposes outlined in this Agreement and in OAC 412317-55. If the employer receives the warrant and uses the grant monies for some other purpose, it shall immediately return the full amount to BWC, and BWC reserves the right to recover grant money by one or more of the following methods: Billing the employer for grant money received, forwarding to the Ohio Attorney General for collections, set-off, recoupment, or other legal remedy. February 2004 TWG-EZ-110 American LegalNet, Inc. www.USCourtForms.com DISQUALIFICATION. If for any reason the employer participating in the BWC’s TWG-EZ program fails to satisfy the requirements of this program in a timely manner, the employer may be disqualified from the TWG-EZ program. BWC reserves the right to conduct an on-site eview if there is reason to believe the program has not been implemented in good faith. Sufficient reason shall include an increase in the number or overall duration of lost-time claims after implementation of the program; such a determination maybe made by an investigation or by data warehouse research. Sufficient reason shall also include reasonable suspicion of fraud orcollusion on the part of the employer. The Employer, if disqualified by BWC, shall immediately return all of the monies to BWC, and BWC reserves the right to recover the grant by the following methods: billing the employer, for the grant money received, forwarding to the Ohio Attorney General for recollection, set-off, recoupment or other legal remedy. If the employer fails to implement the program within one (1) year, the grant monies shall be considered misappropriated, and the employer shall repay the amount of the grant immediately, and BWC reserves the right to recover grant money by one or more of the following methods: billing the Employer for the grant money received, forwarding to the Ohio Attorney General for collection, set-off, recoupment, or other legal remedy. PURPOSE AND DISCLAIMER. If implemented correctly by the employer, the goal of the TWG-EZ program is to reduce the incidence of lost-time claims and the duration of such clams by the employees of the employer. In the event of an injury or occupational disease arising from the implementation of the program, the employer’s and the employee’s sole and exclusive remedy shall be pursuant to workers’ compensation laws of the appropriate jurisdiction. In no event shall BWC be liable for any damages in contract or in tort. MODIFICATIONS. The parties may in writing and by mutual agreement, amend, modify, supplement or rescind the terms of this agreement. AUTHORITY. The person signing below for the employer states that he or she is either the owner, CEO, CFO, plant manager, or other person having fiduciary responsibilities with the employer, and the employer agrees that that the signer or his or her successor will have the authority to over see the carrying out of the employer’s responsibilities for two years after BWC issues the grant warrant. The signer’s authority shall continue until the employer notifies BWC of the name of the successor. The signer on his or her own behalf and on behalf of the employer agrees to comply fully with the terms and conditions of this Agreement and the program and to utilize all monies solely for the purpose or purposes intended and understands that he or she and the employer may be subject to civil, criminal and administrative penalties as a result of any false, misleading or fraudulent statement of if the monies are not used or are misused, misapplied or misappropriated in any way. IN WITNESS WHEREOF, the parties hereunto affix their signature this ______ day of _______________________ , 20____. Signature ____________________________________________________ Ohio Bureau of Workers’ Compensation Title _________________________________________________________ __________________________________________________________ James Conrad, Administrator/CEO American LegalNet, Inc. www.USCourtForms.com